The death of over 100 children in about a month in Muzaffarpur district of north Bihar due to low blood sugar level is caused by a toxin present in litchi fruit. When under-nourished children eat the fruit and go to bed on empty stomach, the blood glucose falls sharply causing severe brain malfunction (encephalopathy) and death in many cases. It can be both prevented and treated.

The death of over 100 children in about a month in Muzaffarpur district of north Bihar due to low blood sugar level could have easily been prevented with some foresight and early care.

Six years ago, a two-member team of Prof. Jacob John and Mukul Das were invited by the State government suspected that a toxin (methylenecyclopropylglycine, MCPG, also known as hypoglycin A) naturally present in litchi fruit was responsible for the mysterious deaths; a large Indo-U.S team confirmed it in 2017, the finding of which were published in January 30, 2017 in the journal Lancet Global Health.

The two-member team found that undernourished children who ate the fruit during the day and went to bed on an empty stomach presented with serious illness early the next morning. In 2014, the team saved 74% of sick children through a simple intervention — infusing 10% dextrose within four hours of the onset of illness.

The recommended prevention strategy — making sure that no child goes to bed without eating a meal — adopted from 2015 ensured a sharp drop in the number of children falling sick. It is appalling that this year the government failed to raise awareness on this strategy.

Government conforms the cause

Worse, some doctors came up with alternative explanations for the illness and even pointed to the heat wave. This is contrary to what the government and the union health minister himself had to say. On June 10, Principal Secretary of the Health Department Sanajy Kumar said the deaths were caused by hypoglycemia (deficiency of glucose or sugar in the blood stream), and not by the fever. Chief Minister Nitish Kumar had said: “It generally hits those children who go to sleep empty stomach at night and eat litchis fallen on the ground” thereby acknowledging the cause of the illness as due to hypoglycaemic encephalopathy caused by the toxin in litchi fruit.

Further confirmation of the cause of the illness came from the State health minister himself. A June 17 news report by ANI says: “Last week, Bihar Health Minister Mangal Pandey had said a team that was formed to ascertain the cause of this disease concluded that sleeping empty stomach at night, dehydration due to humidity and eating lychee on empty stomach were some of the causes of encephalitis.” However, it is not encephalitis (which is caused by virus) but encephalopathy caused by low blood sugar.

The State government said that most of the children have died due to hypoglycemia, a medical condition caused by very low levels of blood sugar and electrolyte imbalance.

Emphasising the need for early detection and treatment of hypoglycemia cases, Union health minister Dr. Harsh Vardhan said that a dedicated team of doctors should be placed in public health centres (PHC) for three to four months before and during the onset of the disease.

Acute encephalitis syndrome

AES is a basket term which includes five causes. While the most common causes of acute encephalitis syndrome are traced to a bacteria or a virus and it takes at least a few days before presenting serious symptoms and deaths, the toxin in litchi causes serious problems overnight.

While well-nourished children who eat the fruit remain unaffected even if they go to bed on an empty stomach, the under-nourished ones are at grave risk. Blood glucose falls sharply causing severe brain malfunction (encephalopathy), leading to seizures and coma, and death in many cases. This is because under-nourished children lack sufficient glucose reserve in the form of glycogen and the production of glucose from non-carbohydrate source is blocked midway leading to low blood sugar level. This causes serious brain function derangement and seizures.

While 5% dextrose infusion serves the purpose in cases of general low blood sugar, children suffering from acute hypoglycaemic encephalopathy can be saved only by infusing 10% dextrose within four hours of illness onset. Recovery is rapid and complete if 10% dextrose is infused within the golden hours. Infusing a higher concentration of dextrose is necessary to completely stop the attempt by the body to produce glucose from non-carbohydrate source. This simple medical intervention could have saved many lives.

Dextrose infusion could have been done even as children were being transported to hospitals in ambulances. The failures were at the stages of both prevention and care.

Published in The Hindu on June 18, 2019